401k Plan data: BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN plan

BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN 401k Plan overview

Plan Name	BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN
Plan identification number	901

BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision)

401k Sponsoring company profile

BLUE GOOSE CANTINA has sponsored the creation of one or more 401k plans.

Company Name: BLUE GOOSE CANTINA

Employer identification number (EIN): 751975501

NAIC Classification: 722511
NAIC Description: Full-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
901 2019-01-01
901 2018-01-01 JOHN BONNO JOHN BONNO 2019-07-18

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
901	2019-01-01
901	2018-01-01	JOHN BONNO		JOHN BONNO	2019-07-18

Plan Statistics for BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN

401k plan membership statisitcs for BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN

Measure Date Value
2019: BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 191
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 150
Total of all active and inactive participants 2019-01-01 150
Total participants 2019-01-01 150
2018: BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 229
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 191
Total of all active and inactive participants 2018-01-01 191
Total participants 2018-01-01 191
Number of employers contributing to the scheme 2018-01-01 1

Measure	Date	Value
2019: BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	191
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	150
Total of all active and inactive participants	2019-01-01	150
Total participants	2019-01-01	150
2018: BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	229
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	191
Total of all active and inactive participants	2018-01-01	191
Total participants	2018-01-01	191
Number of employers contributing to the scheme	2018-01-01	1

Form 5500 Responses for BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN

2019: BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

ASSURED BENEFITS ADMINISTRATORS (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

6168

Policy instance

Insurance contract or identification number	6168
Number of Individuals Covered	162
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,750
Total amount of fees paid to insurance company	USD $398
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,750
Amount paid for insurance broker fees	398
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES

ALLIED NATIONAL COMPANIES (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

Policy instance

Number of Individuals Covered	1800825
Insurance policy start date	2001-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $8,831
Total amount of fees paid to insurance company	USD $1,474
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,713
Amount paid for insurance broker fees	1078673
Additional information about fees paid to insurance broker	ADMINISTRATION FEES

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Company Name:	BLUE GOOSE CANTINA
Employer identification number (EIN):	751975501
NAIC Classification:	722511
NAIC Description:	Full-Service Restaurants